I   First Name   Last Name, do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   
Date   

I,   First Name   Last Name  , certify that I do not receive income from any of the following sources: 

• Wages from employment (including commissions, tips, bonuses, etc.); 
• Rental income from real or personal property; 
• Interest or dividends from assets; 
• Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits; 
• Unemployment
• Periodic allowances such as alimony, child support. 

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.

Signature   

Date   

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I   First Name   Last Name (spouse/legal partner), do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   Spouse/Legal Partner
Date   

I,   First Name   Last Name  (SPOUSE/Legal Partner), certify that I do not receive income from any of the following sources: 

• Wages from employment (including commissions, tips, bonuses, etc.); 
• Rental income from real or personal property; 
• Interest or dividends from assets; 
• Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits; 
• Unemployment
• Periodic allowances such as alimony, child support. 

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.

Signature   SPOUSE/Legal Partner

Date   

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I   First Name   Last Name (dependant), do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   Dependant
Date   

I   First Name   Last Name (dependant), do hereby certify that all the above income information for the past 3 months is true and correct.

Signature   Dependant
Date